台灣厭食症女性之復原經驗：多個案研究

Abstract

在台灣，學界與實務界對厭食症的理解，相當受西方個人主義與後實證典範之醫療觀點所限，而缺乏對本土文化背景之敏感度。本研究意在理解：台灣女性厭食症案主在當代華人社會文化脈絡下的 1)主觀復原經驗、2)對自身罹病與復原經驗之理解。本研究採用Bronfenbrenner的人類發展之生態模式為主要理論視框，輔以華人本土心理學、跨文化心理學之重要理論概念為資料分析參照。

本研究採多個案研究法，依照研究參與者所能提供之復原經驗豐富程度，一共探究三名女性厭食症復原者之生活/生命經驗。三名研究參與者各自經歷不同之厭食症亞型、罹病時間長短不一、研究進行當下亦處於不同復原階段，以求提升研究結果之多元性與全面性，本研究依循個案研究法蒐集多元形式的質性資料，以豐厚研究所能呈現之參與者經驗，資料來源有：半結構回溯式深度訪談、受訪者復原期間所紀錄之個人生活札記、飲食日誌、圖像創作等；所有非語言資料，皆由參與者在訪談過程中描述解說，化為可分析之文字資料。資料分析過程如下：三位受訪者的經驗先被視為三個各自獨立的單一個案來分析，接著進行跨個案間比較分析。資料分析法採主題分析，首先，依人類發展之生態理論為模型，用演繹式(上而下)分析法將所有原始資料略分類於不同生態系統層次；再者，以歸納式(下而上)分析法，辨識出三位參與者在各層系統中的顯著主題；最後，比對與對比三位參與者之間相似與殊異之主題。

跨個案分析結果揭示12項三位受訪者共享之顯著主題：個人層次有「人格特質乃雙面刃」、「自助」；微系統層次有「厭食症的發展和復原與家庭動力有關」、「關係上的支持」、「專業協助與治療關係」；宏觀系統層次有「西方文化涵化與厭食症及復原」、「華人文化價值觀念對厭食與復原的影響」、「社會價值觀與厭食症之間的雙向性」；受訪者對厭食與復原之理解有「賦予復原經驗正面意義」、「個人復原經驗乃獨一無二」、「復原乃一系統性、多面向、整體性的轉化與蛻變」、「復原是連續性的歷程，並有其進程與階段性」。

本研究發現：厭食症復原乃當事人與所身處的脈絡之間的互動歷程，當事人的復原經驗在特定系統層次內、跨系統層次間，持續交互作用與共同建構。研究結果亦指出：當事人的復原經驗與當代台灣社會文化歷史脈絡 (如：西方涵化；關係主義社會強調和諧、家族、面子等；心理疾病之汙名化；成長中的心理衛生專業等) 密切相關。

本研究結果提供本土厭食症臨床工作與研究，一有別於現行西方個人主義心理學與後實證醫療取徑之替代性觀點。研究結果可用於：1) 台灣心理衛生專業人員對主流厭食症理論與處遇模式之反思；2) 賦能女性厭食者解構主流社會所認定之「女性特質」，拾回復原之主體性；3) 協助研究者與實務工作者發展對當代台灣厭食症案主與案家，較具文化適切性與敏感度之處遇模式。In Taiwan, understandings surrounding Anorexia are primarily limited to the western psycho-medical perspectives, which are based on a both European individualism and post-positivism paradigm. The current study takes a context-informed and culturally-sensitive perspective in order to comprehend women’s subjective experiences and sense-making during recovery from anorexia in contemporary Taiwan. Bronfenbrenner’s ecological model of human development served as the primary theoretical framework and theories and constructs derived from Chinese indigenous psychology and cross-culture psychology were drawn on as conceptual and analytical references.

This study followed a multiple case study design where three women, subject to different subtypes of anorexia for various lengths of time and at different stages of recovery, were selected due to the information richness of their experiences. Multiple forms of data were collected from retrospective in-depth semi-structural interviews, journal entries, eating diaries, pictorial records, which were made during recovery. Each participant’s experiences were treated as a single case followed by cross-case comparisons and contrasts. Data were analyzed using a mixture of inductive and deductive thematic analysis, within each case, to identify salient themes in each ecological system. Afterward, salient themes across all three cases were recorded as well as those distinctive to any of them.

Cross-case analysis revealed 12 merged themes: personality traits as a double edged sword and self-help within the individual system, anorexia and recovery associated with family dynamics, relational supports, professional help and therapeutic relationship on the micro-system, anorexia and recovery under western acculturation, Chinese cultural values/constructs interrelated with anorexia and recovery, and bidirectional influences between societal values and anorexia on the macro-system; positive meaning making of recovery, recovery is idiographic in its nature, recovery entailed systemic, multifaceted, and integral transformations, recovery is progressive and stage-like with regard to sense-making of recovery.

Overall, findings suggested the interactive nature of anorexia recovery as a reciprocal process between persons and their contexts, within and among various ecological systems. Results also indicated participants’ experiences were related to the specific social, cultural, and historical contexts associated with Taiwan (e.g., western acculturation, emphasis of a relational society on harmony, family, face, stigmatization of the mentally ill, and mental health profession maturity).

This research provides an alternative to existing theories and clinical works in anorexia that are mainly based on European individualistic psychology and post-positivistic medical perspectives. Results may be used (a) to encourage mental health professionals in Taiwan to reflect on dominant theories and conventional interventions, (b) to empower women with anorexia to deconstruct dominant social values on femininity and to take on an agent role in recovery, (c) to help researchers and practitioners to develop more culturally-appropriate interventions for Taiwanese individuals and families who live with anorexia in contemporary Taiwanese contexts.